Healthcare Provider Details

I. General information

NPI: 1740416320
Provider Name (Legal Business Name): CARLOS M MORALES MITTI B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 CHESTNUT ST 5TH FLOOR
PHILADELPHIA PA
19107-4101
US

IV. Provider business mailing address

2757 CORAL ST
PHILADELPHIA PA
19134-4039
US

V. Phone/Fax

Practice location:
  • Phone: 215-851-1822
  • Fax: 215-851-1775
Mailing address:
  • Phone: 215-459-7301
  • Fax: 215-851-1775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: